* obligatory fields

Please be advised that the personal data collected in the report will be processed by Accord Healthcare Ireland Ltd. (Sage House, 319 Pinner Road, North Harrow. Middlesex, HA1. 4AF, United Kingdom) and used exclusively for the purposes related to the obligation to monitor the safety of medicines. Every person has the right to access and correct their data. Under the Pharmaceutical Law Act, art. 36, September 6th 2001, providing data indicated above by symbol * is mandatory . Providing other data is voluntary.